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Case Study Assessment and Treatment Recommendations
Teles Ribeiro
School of Behavioral Sciences, Liberty University
PSYC 305: Overview of Theory & Treatment of Substance Abuse
Dr. Robert Clark
Oct 11, 2024
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Case Study Assessment and Treatment Recommendations
Name: Hannah
Age: 42 years old
Evaluator: Teles Ribeiro
Reason for Assessment
Hannah sought an assessment for her substance use issues after experiencing several
setbacks in her efforts to overcome addiction. This assessment is critical to help diagnose the
extent of her drug use, the substances she’s abusing, and the underlying causes contributing to
her continued use. Furthermore, Hannah has a history of repeated relapses after attempts at
recovery, which suggests that there may be deeper psychological and emotional issues at play.
Without a thorough evaluation, it is difficult to create an effective treatment plan that addresses
both the physical and mental aspects of her addiction.
It is crucial to determine if there are any patterns in her drug use, such as specific triggers
or underlying mental health issues, that may be contributing to her inability to remain sober.
Additionally, the assessment will explore her family and social environment to better understand
the support—or lack thereof—available to her. Comprehensive understanding of these factors
will guide the creation of an individualized treatment plan.
Sources of Information
The primary source of information for this assessment is Hannah herself, providing first-
hand insight into her experience with drug use and her attempts to quit. However, it is also
important to include observations from her ex-husband, who has reported instances of erratic
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behavior, paranoia, and extreme agitation. His input is valuable in understanding how Hannah’s
addiction manifests externally, particularly how it affects her relationships and interactions with
others.
While Hannah’s account will provide personal details of her struggle, third-party
observations are essential in offering a more complete picture of her addiction. Often, individuals
dealing with substance abuse may not fully recognize the severity of their behavior or its impact
on those around them. By incorporating these external perspectives, a clearer, more objective
assessment can be made.
Background Information
Hannah’s background reveals a troubling pattern of addiction and relapse. Unfortunately,
little is known about the exact circumstances that led to her initial drug use, which makes it more
challenging to assess her situation. However, what we do know is that she has been in and out of
various rehabilitation centers, but has consistently failed to remain sober for more than 30 days
outside of these controlled environments. This repeated failure indicates a strong psychological
dependence on drugs, compounded by a lack of coping mechanisms to deal with life outside of
rehab.
Hannah’s addiction has taken a heavy toll on her life. Once employed as a social worker,
she lost her job due to her drug use, which directly impacted her financial stability and sense of
self-worth. Losing her job also contributed to her social isolation, as she lost the daily structure
and sense of purpose that her profession once provided. Additionally, her addiction caused her to
lose custody of her children, further deepening her emotional distress and isolation. She now
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lives with her mother, who has taken on the responsibility of caring for her. However, this
arrangement is not sustainable, as her mother is growing weary of the burden, expressing
frustration over having to care for her adult daughter.
Current Status
Hannah’s current situation is bleak. She is entirely dependent on her mother for support,
both financially and emotionally. Her mother, however, is exhausted by the responsibility and
has openly expressed that she is "too old" to continue caring for her. This strained relationship
adds to Hannah’s feelings of guilt and shame, which may be contributing to her ongoing drug use
as a form of self-medication. Without a strong support system in place, Hannah is left feeling
isolated and without the resources necessary to break free from her addiction.
Hannah’s emotional state is likely exacerbated by the fact that she has lost custody of her
children. The loss of her role as a mother, combined with her estrangement from her ex-husband
and other family members, leaves her feeling disconnected from the people who were once
central to her life. This loss of connection and purpose could be fueling her addiction, as she
turns to drugs to fill the void left by these broken relationships.
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Attitude and Behavior
Hannah exhibits several troubling behaviors, as reported by her ex-husband. Her erratic
actions, paranoia, and extreme agitation suggest that her drug use may be affecting her mental
health in significant ways. These behaviors could be signs of a co-occurring mental health
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disorder, such as anxiety or schizophrenia, which would need to be addressed alongside her
addiction in order for her to achieve long-term recovery.
Hannah herself acknowledges that her mother is tired of taking care of her, yet she
remains in her mother’s home without making any efforts to find employment or become more
self-sufficient. This lack of motivation could be a symptom of depression, another common
mental health issue associated with substance use. Without addressing these underlying
psychological issues, it is unlikely that Hannah will be able to maintain sobriety in the long term.
Social Functioning
Hannah’s social life has deteriorated significantly due to her addiction. She has lost most,
if not all, of her friendships, largely because of her continued drug use. Her family relationships
have also suffered, with her mother being the only remaining connection, albeit a strained one.
Social isolation is a common issue among individuals struggling with addiction, as their behavior
often alienates them from loved ones. In Hannah’s case, her isolation only serves to perpetuate
her addiction, as she lacks a support network to encourage her in her recovery efforts.
Social support is a critical component of addiction recovery. Without meaningful
connections to friends or family, individuals often struggle to stay sober, as they lack the
emotional reinforcement necessary to make positive changes. Rebuilding Hannah’s social
network will be an important part of her treatment, as reconnecting with supportive people could
provide her with the encouragement and accountability she needs to stay on track.
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Occupational Functioning
Prior to her addiction, Hannah was employed as a social worker, a role that likely gave
her a strong sense of purpose and identity. However, her drug use led to the loss of her job, which
has had devastating consequences on her self-esteem and financial independence. She is now
unemployed and has made no effort to seek new employment, which may be due in part to the
effects of her addiction. The loss of her professional identity may be contributing to her feelings
of hopelessness and further entrenching her in her drug use.
Re-establishing Hannah’s occupational functioning will be essential to her recovery.
Employment can provide structure, a sense of purpose, and financial independence, all of which
are crucial for maintaining long-term sobriety. However, Hannah will need support in
overcoming her addiction before she can realistically return to the workforce. This may involve
vocational training or job placement programs tailored to individuals recovering from substance
use disorders.
Financial Aspects
Hannah’s financial situation is precarious. She has no income and relies entirely on her
mother for financial support. This dependency further strains their relationship, as her mother is
not only providing for her basic needs but also shouldering the emotional burden of caring for an
adult child who has not been able to regain her independence. Hannah’s financial struggles are
compounded by the fact that she inherited a significant sum of money from her grandmother, all
of which she spent on drugs. This financial mismanagement is a clear indicator of the extent of
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her addiction, as it demonstrates her willingness to sacrifice long-term stability for short-term
relief.
Addressing Hannah’s financial instability will be a key part of her treatment. Financial
counseling could help her develop better money management skills, while job placement
services could assist her in finding employment once she is ready. Additionally, involving her
mother in family therapy could help them develop healthier financial boundaries, reducing the
strain on their relationship.
Familial Relationships
Hannah’s relationships with her family members are deeply fractured. Her addiction has
caused her to lose custody of her children, and she is estranged from her ex-husband and other
relatives. The only family member she remains in contact with is her mother, who provides her
with shelter and financial support. However, this relationship is strained, as her mother has
expressed frustration and exhaustion over having to care for an adult child who is unable to
function independently.
Rebuilding Hannah’s family relationships will be an important part of her recovery
process. Family therapy could help address the emotional wounds caused by her addiction and
create a healthier dynamic between Hannah and her mother. Additionally, reconnecting with her
children, even in a limited capacity, could provide her with a sense of purpose and motivation to
stay sober.
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Legal History
Although no specific legal issues are detailed in the case study, it is likely that Hannah’s
addiction played a role in legal proceedings concerning the custody of her children. Addiction
often leads to involvement with the legal system, whether through custody disputes, criminal
charges related to drug use, or other legal matters. It will be important to explore whether
Hannah has any outstanding legal issues that need to be addressed as part of her recovery plan.
Health History
Hannah’s physical health has suffered greatly as a result of her addiction. She has lost a
significant amount of weight, has trouble sleeping, and often neglects her hygiene and nutritional
needs. Additionally, she reports feeling frequently ill over the past few years, which may be due
to the toll that drug use has taken on her body. Poor physical health is a common consequence of
long-term substance use, as individuals often prioritize their addiction over their well-being.
Improving Hannah’s physical health will be a key focus of her treatment. This may
involve working with healthcare providers to address any underlying medical conditions, as well
as incorporating nutrition and exercise into her recovery plan. By improving her physical health,
Hannah may begin to feel better
Spiritual History
No information about Hannah's spiritual background or beliefs is mentioned in the case.
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Indicators of Use/Abuse/Dependency
Hannah has a history of using prescription drugs, cocaine, and methamphetamine. She
has been unable to stay sober for more than 30 days and admits that her substance use has been
steadily increasing. Her drug use has impaired her daily life, leading to physical, emotional, and
social decline. She also reports experiencing hallucinations during a previous rehab stay, where
she believed doctors and nurses controlled her behavior, even when she was no longer in the
facility.
Diagnostic Impression
Based on the information provided, it’s clear that Hannah suffers from severe substance
use disorder, likely involving both cocaine and methamphetamine. Her inability to maintain
sobriety, coupled with her history of multiple relapses, indicates a deep dependency on these
substances. Her drug use has caused significant physical, emotional, and social impairments, and
her condition is worsening without intervention.
Recommendations
To begin addressing her complex issues, Hannah would benefit from intensive treatment
in a structured environment. Given her history of relapses after short-term programs, a long-
term residential rehabilitation program should be considered, offering 24-hour support and a
comprehensive approach to her addiction. In addition to traditional methods, such as cognitive-
behavioral therapy (CBT) and group therapy, Hannah would benefit from dual-diagnosis
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treatment to address the possible psychosis she has reported, which may involve hallucinations
and paranoia.
Her treatment plan should also include family therapy, as rebuilding her relationships
with her mother and children could provide emotional support and stability that may aid in her
recovery. Finally, Hannah needs assistance with life skills training and occupational counseling
to regain independence and avoid future relapse. Since she has expressed concern about
managing money responsibly, financial counseling should also be incorporated into her treatment
plan.
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References
Neiswonger, C. (2024). Case study assessment and treatment recommendations.
Liberty University.
Kelley, B. M. (2021). Drug abuse across the lifespan: A biopsychosocial
approach. Kendall Hunt Publishing.
